ehr implementation with minimal practice disruption in primary care settings

EHR Implementation with Minimal Practice Disruption in Primary Care Settings: The Experience of

the Washington & Idaho Regional Extension Center

November 2012

Washington & Idaho Regional Extension Center

www.wirecQH.org

wirecA Qualis Health Program

Authored by:

Jeff Hummel, MD, MPHQualis HealthSeattle, Washington

Peggy Evans, PhD, CPHITQualis HealthSeattle, Washington

With contributions from the WIREC consultant team

EHR Implementation with Minimal Practice Disruption in Primary Care Settings | of 15

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Case Study Vignettes . . . . . . . . . . . . . . . . . . . . . . . . . .5

Table 1: The most common errors in

EHR implementation contributing

to practice disruption . . . . . . . . . . . . . . . . . . . . . . . . . .7

Leadership Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Workflow Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Provider Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Training Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Data Interface Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .11

User Interface Issues . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15


Executive Summary

The US government has created financial incentives for

healthcare organizations and eligible professionals to

use electronic health record (EHR) systems in a manner

that meets the Centers for Medicare & Medicaid Services

(CMS) defined criteria for “meaningful use.” At the same

time, experiences of larger delivery systems that have

implemented EHRs indicate a variety of pitfalls associated

with health IT adoption that may contribute to financial

loss and practice disruption impacting patient care.

The Regional Extension Center for Health Information

Technology (REC) program is a federally-funded program

administered by the Office of the National Coordinator for

Health Information Technology (ONC). The REC program

focuses on providing technical assistance for EHR

implementation to small primary care practices, a group

for which the health IT adoption experience has been

less well understood. The Washington & Idaho Regional

Extension Center (WIREC), a program of Qualis Health,

has identified important patterns in implementation

errors that result in financial loss, practice disruption and

patient safety issues. In this white paper, we describe

these errors and how they pertain to leadership, workflow,

provider engagement, training, data interfaces and the

user interface. For each category, we describe the errors

in detail and recommend specific strategies that primary

care practices of all sizes can use to minimize the risk of

practice disruption and the associated costs.

What are Regional Extension Centers?

The Office of the National Coordinator for Health

Information technology (ONC) funded 62 Regional

Extension Centers (RECs) across the country to help

more than 100,000 primary care providers adopt and use

electronic health records (EHRs) and receive incentive

payments through the Medicare and Medicaid EHR

Incentive Programs for the “meaningful use” of their

EHR systems.

REC services include outreach and education, EHR

vendor support, workflow redesign assistance, change

management support and other technical assistance for

the successful implementation and utilization of health IT.

In particular, the RECs focus on individual and small

practices (fewer than 10 providers), federally qualified

health centers, rural health clinics and other settings that

predominately provide services to the underserved.


Introduction

Studies on electronic health record (EHR) implementation

have documented the difficulty of the process (1, 2) such

as the high costs, lowered productivity, disruption to

patient care and dissatisfaction among staff. Yet most

of the research on EHR implementation challenges

comes from large organizations and/or academic

institutions (3, 4). The Regional Extension Centers for

Health Information Technology (REC) program has

resulted in new insight into the specific challenges that

smaller practices face when implementing an EHR (5). The

experience of one such REC program, the Washington

& Idaho Regional Extension Center (WIREC) is

documented in this paper.

WIREC is a program of Qualis Health, a nonprofit

healthcare consulting organization. WIREC delivers

health IT consulting services to over 3,300 primary

care providers in the Pacific Northwest in more than

630 practice locations with an average of 4 providers

per practice. By the third year of the grant-funded

program WIREC had assisted 77% of its enrolled

providers in fully implementing an ONC-ACTB certified

EHR. Through these experiences WIREC has gained

valuable insight into the factors determining the

success—or failure—of EHR adoption in small practices.

Background

EHR implementation is a complex orchestration of

information technology and business process “system

builds.” Successful implementation requires that end

users understand each workflow, that all technology

components work properly with the corresponding

workflow and that each end user knows how to

use relevant software components. However, the

implementation timeline and focus are invariably

technology-driven with go-live as the culminating event

in which all EHR components are turned on, used

simultaneously and expected to work properly.

In reality, the implementation of EHRs in ambulatory

clinics frequently follows the psychological roller coaster

of the Gartner Hype-Cycle (6), in which unrealistic

expectations reach a peak just prior to implementation.

What follows is a “trough of disillusionment” and a

recovery phase requiring hard work to understand how

the technology best fits the users’ needs, all under the

pressure of reduced productivity. A clinic can avoid the

extremes of the Hype Cycle and have a more successful

implementation by doing much of the same recovery work

in advance including setting expectations, planning for

change management, preparing workflow changes and

avoiding common errors.

The vignettes on the following pages, assembled from the

experiences of WIREC consultants, illustrate the factors

that contribute to the success or failure of implementation.


Case Study Vignettes

Clinic A:

Clinic A had difficulty choosing an EHR system largely

because the vendor selection group lacked agreement

about key workflows and organizational priorities. After

finally selecting an EHR, the CEO of the organization

and driver of the EHR adoption process appeared to

lose interest and stopped attending planning meetings,

delegating leadership tasks to a low-level aid. The

providers, taking their cue from leadership, likewise

disengaged from the planning process, not focusing on

critical tasks that need to be completed in advance such

as workflow redesign. The EHR vendor gave the clinic a

list of tasks such as creating charting templates, order

sets and diagnosis preference lists, however no one in

the clinic took responsibility for making sure each task

was understood and completed. Training took place

one month before go-live and there was no additional

reality-based training the week of go-live, which is

a crucial period for training. The end result was that

providers and staff were equally dissatisfied with the

EHR and EHR implementation process.

Clinic B:

The two physicians who owned the clinic made the EHR

selection decision without input from employees including

other providers. The planning process was autocratic,

leading to disengagement first by providers and then by

other employees following their example. Decisions about

placement of terminals and printers were made without

input from the front line personnel who would be using the

equipment. Several medical records clerks were assigned

to scanning entire paper charts in preparation for the

implementation, which diverted staff time from more

important preparatory work, filled up valuable space on

the server, and saved clinical information in a format that

was difficult to access and impossible to search. There

were several meetings to review workflow, but without a

strong facilitator and organizational support the meetings

usually lost focus. In order to reduce costs, a small

number of non-provider clinic personnel were trained as

EHR super-users and given responsibility for training the

rest of the staff over several months before go-live, which

was too early to be of real value. “Go-live” on the EHR

was scheduled when one of the clinic owners and key

advocate of the EHR implementation was on vacation and

unable to address issues. All features of the EHR were

turned on at once in a “big bang” approach. Providers

were frustrated with the go-live process, complaining

loudly in the hallways. Both staff and providers felt

demoralized by the end of the implementation process.


Clinic C:

Clinic C had a senior physician whose role was the clinician champion for the EHR rollout. He led planning meetings

and sent out weekly communications to all clinic staff setting expectations for how the practice would change. The

clinician champion also engaged two other providers to endorse the EHR and assist with clinic change management

processes. While still using paper charts, the clinic mapped and standardized key workflows to plan how the processes

would work with the EHR. The EHR committee, led by these three physicians, met weekly to build templates, order sets

and preference lists. After planning for the 100 most frequently used diagnoses at the clinic, they developed a process

for setting up new tools after go-live. The clinic hired two employees to enter a limited set of key clinical information

into the EHR data fields including medications and past medical history in the weeks before go-live. Ongoing training

was required for both staff and providers. When the clinic finally started to implement the EHR, they went live with one

team at a time, allowing ample time to address issues and solve problems as they emerged. On-site trainers focused

their support on the team going live, but were also available to teams that had just completed implementation. The

implementation was perceived as having gone smoothly, and the drop in productivity at any given time was comparable

to having one or two providers on vacation.

The vignettes described, which are based on the

real-experiences of clinics, reveal patterns in EHR

implementation that can result in either avoidable errors

(Clinics A and B) or successful adoption (Clinic C). The

WIREC team has seen these patterns repeatedly, albeit

each clinic experiences the “pain” in somewhat different

ways. Each error carries associated costs that reduce the

likelihood of successful adoption, seriously jeopardize a

medical practice’s financial viability and negatively impact

patient care. The causes of practice disruption through

implementation errors were organized into six categories

that are not necessarily mutually exclusive as shown in the

following table. The pattern suggests a set of strategies

and resources to help clinics reduce practice disruption

during EHR implementation.


Table 1: The Most Common Errors in EHR Implementation Contributing to Practice Disruption

Type of Error Detailed Description

Leadership Issues

• Lack of unconditional leadership support with the skills, knowledge and engagement to manage the project.

• Poor decision-making structure, or the wrong people in leadership to drive the health IT project.

• Lack of good bi-directional communication between leadership and staff.

• Failure to understand of the principles of change management.

Workflow Issues

• Failure to understand the overwhelming importance of workflow in determining productivity, and inadequate workflow mapping prior to go-live.

• Failure to set up an “easiest way” to see patients and document visits prior to go live.

• Failure to assign specific roles for data gathering and data entry.

• Failure to do a full walk-through to identify gaps, bottlenecks and optimal location of devices to support workflows.

Provider Issues

• Absence of a strong clinical champion.

• Failure to have full provider support for the project or provider participation in the selection process including which devices to use.

• Failure of providers to understand their role in utilizing the EHR leading to counterproductive physician behavior such as not attending user training and lack of cooperation or participation in workflow redesign efforts.

Training Issues

• Underestimation of the amount of training required.

• Failure to time the training to when users can optimally absorb it. Too much training takes place before users have a context to understand it.

• Failure to assure that providers actually complete training.

• Failure to have a full dress rehearsal before go-live.

• Failure to provide sufficient real-time support during go-live when the risks are greatest, the learning potential is highest and when staff need training the most.

Data Interface Issues

• Failure to build, test and implement all essential interfaces for lab and imaging prior to go-live.

• Failure to migrate the right information from legacy systems and paper records into the EHR.

User Interface Issues

• Failure to properly configure essential EHR features required for patient care, and to assure they are properly turned on and tested.

• Failure to create and test tools such as charting templates and preference lists needed to see patients, place orders and document visits.

• Failure to organize charting tools so care team can easily find them.

• Failure to limit the amount of customization prior to go-live.

• Failure to plan for prioritizing fixes and customization for system optimization after go-live.


While the six errors listed in Table 1 are common, they are also avoidable through careful planning and measures

described below.

Leadership Issues

Common ErrorsMost leadership problems stem from inadequate

leadership support and failure to manage the EHR

implementation project. This is often compounded by a

lack of skills, knowledge, and understanding of change

management principles. Frequently, smaller practices

have instituted decision-making processes that lack

structure including formal communications with staff.

Leadership for EHR implementation can include a variety

of personnel ranging from the CEO to clinic staff with a

knack for project management, for example a medical

assistant. Regardless of who plays a leadership role, the

key concept is that those people must have organizational

support, ability to remove barriers, strong framework for

communications plans for all staff members and sufficient

time allocated to lead the EHR project.

Recommendations1. Leadership at the highest level (e.g., CEO) is

responsible for establishing organizational aims for

the EHR and assuring that the strategies to achieve

those aims are executed at the highest governance

level. This requires articulating a business case

for clinical quality as well as allocating resources,

removing barriers and fully engaging providers

and patients.

2. Other more informal leadership, including clinician

champions, can help build a shared understanding

of the need to use information technology to measure

and manage clinical quality. Clinician champions are

essential for solidifying provider support based on

an agreement for how the EHR will be used to

improve patient care.

3. Leadership must develop a framework for clear and

rapid communications about health IT priorities within

the clinic, both for top-down as well as bottom-up

communications. This may include, for example,

weekly emails, all-staff meetings or a bulletin board

in the break room to communicate with the staff

about rapidly evolving situations.

4. Leadership’s role is to help the entire clinic

understand that they are embarking on continuous

practice transformation that happens to involve

technology, not a technology project that happens

to involve healthcare.

5. Leaders must dedicate sufficient time to leading the

EHR project. It is unrealistic to expect those in

leadership positions to manage the EHR rollout as

“one more thing” on their plates. The project lead, for

example, should have at least half of his or her time

devoted specifically to the EHR rollout.


Workflow Issues

Common ErrorsClinical personnel, including providers, often have little insight into the clinic’s workflows and the roles others play in care

delivery. This blind spot results in inadequate planning for the most important determinant of successful implementation.

Most organizations must go back after go-live to fix (i.e. standardize) workflows in an effort to recover from the resulting

productivity drop. Without identifying a standardized best practice method to do the work, every user is left to struggle

alone with a complex and confusing user interface without agreement on how information should be gathered, who

should enter it and where it is entered. There is commonly a lack of agreement on how the information is processed

and organized, and finally where in the workflow the information will be used and by whom. Performing a pre go-live

“walk-through” to visualize how information flow integrates with workflow allows the team to optimize processes in

advance. It also avoids improper placement of hardware including workstations, printers and scanners that can be

costly, or impossible because of clinic layout to repair after go-live.

Recommendations 1. Clinics should map and standardize their key workflows before EHR selection, using what they learn to determine

which EHR tools best support their workflows. If that pre-step has been missed, workflows should be mapped

before EHR implementation. Relying on vendor-suggested standard workflows rarely works because the set-up of

each practice is different and clinic personnel need a clear understanding of how the technology supports their own

workflows. Workflows should be mapped and redesigned by the front line staff doing the work and should include

both current processes as well as envisioned future processes. On-site walk-through exercises should be conducted

to assure that devices are placed and the technology is configured to deliver the right information, formatted properly,

to the right person at the right time.

2. Clinics should plan to spend additional time redesigning workflows after the EHR has been implemented as well

as before implementation. In order for an EHR to increase efficiency, improve clinical care and enhance patient safety,

clinic staff must understand how information is gathered and entered into the EHR, how information is processed and

organized within the EHR, and where the information is used in the workflows to support the clinical decisions that

affect patient care. After the EHR is implemented, it is common for there to be confusion about which staff should

enter specific information, which data fields to use and where in the workflow data entry should happen. Once the

optimal processes for integrating information and workflow have been determined, they must be communicated

adequately to staff.

3. In general, data entry by providers should be confined to actual clinical decisions such as ordering tests, ordering

medications or placing diagnoses on the problem list. Whenever possible, support staff should enter other data as

appropriate given staff licensure. Even orders for medications and tests can often be “set up” by support staff using

written protocols in which the provider pushes the button to place the order.


Provider Issues

Common Errors Many EHR implementation projects fail from

underestimating the importance of one or more strong

clinician champions to serve as opinion leaders for

providers in the clinic. The clinician champion must

guide colleagues in understanding their roles in the

implementation and enlisting their involvement in such

complex tasks as EHR selection, workflow redesign,

template development and quality improvement (7).

Without a champion, dysfunctional physician behavior

can easily undermine the project with negative messaging

to staff, and, at its worst, it can result in “hijacking” the

project through endless demands for poorly thought-out

changes that delay implementation and prolong the

stabilization period.

Recommendations1. Identify one or two clinician champions and

define their roles.

2. Work with the clinician champion(s) to engage

providers early in the EHR selection and

adoption process.

3. Focus on efforts to reduce waste and improve

clinical outcomes using the early adopters to lead

the effort. Enlist more reticent providers to review

plans and point out what could go wrong.

4. Leadership must include the clinical champion(s) in

tactical decisions to avoid common errors and

make difficult judgment calls including how much

optimization can reasonably be completed

before go-live and what to delay until after

system stabilization.

Training Issues

Common Errors Vendors frequently limit training to didactic sessions organized by technology feature and taking place weeks before go-live. Clinics often underestimate the number of hours they need for training in efforts to reduce costs, or they may opt for over-the-phone (versus in person) training to avoid vendor travel costs. Providers often assume they can learn anything on the spot, and may skip aspects of training altogether. These patterns can all contribute to a dynamic in which clinics receive inadequate training, forego a full dress rehearsal and end

up going live unprepared.

Recommendations1. Help clinic leadership understand the importance

of spending money to appropriately train staff.

Consider a “train the trainer” approach, in which the

vendor trains “super users” from the organization, who

in turn, are responsible for coaching other staff.

2. Training should be as reality-based as possible.

Providers learn by entering problem lists, medications,

and preventive information on their own patients into

the production EHR. In a test environment providers

can use live patient simulations to document visits and

place orders.

3. Consider going live with clinical support staff before

providers, or hiring additional “training staff” so

adequate support is available for providers during go

live. Providers are juggling the most complex medical

thought processes, multiple distractions and major

time constraints while learning the most complicated

and broadest scope of the EHR environment.

4. Practice each major workflow repeatedly just

before and during go-live. Workflows to rehearse

include rooming patients, ordering common tests

or procedures (medications, imaging, blood

work, injections, ECGs, referrals, etc), and

end-of-visit scenarios.


Data Interface Issues

Common ErrorsEHRs must make it easier for care teams to find

information. Failure to complete and adequately test

data interfaces (e.g., lab, radiology) before go-live

results in “work-arounds” that contribute to

post-implementation costs by wasting valuable

staff and provider time handling or looking for

information needed at the point-of-care for clinical

decision making. Additionally, errors or gaps in data

migration from legacy systems or paper charts

contribute to post implementation costs by:

1. Failing to capture data likely to be required for

clinical decisions such as old electrocardiograms

and immunization data.

2. Storing important information in ways that make it

difficult to find, such as scanning immunization

records versus entering the data into discrete fields

where the data can be found through a search or

reporting function.

3. Wasting resources entering old information into the

EHR that is unlikely to be used in the future such as

old progress notes.

Recommendations1. Do not go live without a fully functional lab interface.

2. Do not scan paper charts in their entirety. Judgment

is required to determine what if anything to scan since

scanned information in an EHR is difficult to find and

unavailable for data processing.

3. Develop a data migration methodology based on

specific information the new system will need (e.g.

information to support prevention guidelines and

metrics for chronic conditions) rather than trying to

preload as much information from the old system

as possible, much of which will be of limited value.

Although somewhat controversial, some organizations

report that having providers enter key data from

paper records into the EHR can be an effective form

of training prior to go-live (8). After go-live make the

paper chart available for patient visits on a limited

basis and design a workflow for care teams to enter

the key information into the EHR.

4. Encourage providers to write 1-2 sentence summaries

of chronic conditions including key milestones as a

short abstract in the problem list instead of scanning

old progress notes.


User Interface Issues

Common ErrorsEHR user interfaces are notoriously complex with many

features essential to a visit crowded into small and

overlapping spaces on the screen. Features that are

not properly configured and thoroughly tested before

go-live may require fixing afterwards at a far greater cost

to the clinic. If a clinic does not set up an “easiest way”

to conduct a visit with basic charting templates the result

is an “everyone for themselves” approach that can spell

disaster. Failure to set up preference lists for diagnoses,

medications or tests leaves providers scrolling through

pages of choices, which is time consuming, frustrating

and error prone. Preparing information management tools

before go-live to create a manageable starting point must

be balanced against the risk of “over-customization” that

can contribute to failure through delay and distraction.

Recommendations1. Set up office visit templates for common types of

visits and office-based procedures.

2. Make preference lists in the EHR with between

5 and 10 choices for diagnoses, medications,

and orders for as many situations as possible

before go live.

3. Make sure flow sheets are working for common

vital signs such as blood pressure and weight, and

for blood tests such as renal function, CBC and lipids.

4. For information management features that cannot

be done before go-live, create a plan for prioritizing

fixes and customization.


Summary

Healthcare organizations of all sizes encounter major

challenges in the course of EHR implementation. At

its worst, these challenges result in wasted resources,

frustrated or alienated providers, loss of confidence

by patients and families and patient safety issues. The

experience of the Regional Extension Centers has

produced sufficient information to describe important

patterns contributing to practice disruption that have

emerged in smaller practices, many of which also apply to

larger organizations.

Without strong and committed leadership to articulate a

vision for change and engage clinician champions who

can communicate their enthusiasm to staff, the risk of

organizational failure is high. Without meticulous attention

to optimizing critical workflows, creating information

management tools to support them and creating a shared

understanding of how information must flow to support

clinical processes, front line caregivers risk becoming

lost in the complexity of the EHR technology. Without

heavy investment in training, rehearsal of critical steps

and onsite support during and immediately after go-live,

EHR implementation can degenerate into a chaotic and

traumatic experience for providers, staff and patients

alike. Finally, without properly working interfaces to lab

and radiology, a clear plan to migrate patient data into

the EHR and ensuring that each feature of the EHR is

configured properly and tested prior to go live, staff will

be left to devise inefficient workarounds that contribute to

dissatisfaction with the EHR.

Practice disruption during EHR implementation causes

increased waste that in addition to the financial impact

can negatively impact care quality or endanger patient

safety (9). Healthcare providers and office staff can be

strong partners for successful implementation if they view

the technology as a tool to make it easier for them do

what they are already trying to do, which is get through

their day with less wasted effort and take better care of

their patients. Carefully executed EHR implementation,

for all its challenges, is necessary for them to be able to

do that.


About WIREC

Led by Qualis Health, WIREC provides vendor-neutral

health IT consulting services related to the successful

adoption, implementation, and utilization of EHRs for the

purposes of improving care. We guide eligible healthcare

professionals to achieve meaningful use of EHRs and

qualify for Centers for Medicare & Medicaid Services

(CMS) incentive payments. WIREC was selected through

an objective review process by the U.S. Department

of Health and Human Services’ Office of the National

Coordinator for Health IT (ONC). WIREC serves as

a direct pipeline to the national Regional Extension

Center program, leveraging our connection to a national

collaborative of RECs while bringing local expertise

to support providers across the region with technical

assistance for successful EHR adoption. For more

information, visit www.wirecQH.org.

About Qualis Health

Qualis Health is a national leader in improving care

delivery and patient outcomes, working with clients

throughout the public and private sector to advance the

quality, efficiency and value of healthcare for millions

of Americans every day. We deliver solutions to ensure

that our partners transform the care they provide, with a

focus on process improvement, care management and

effective use of health information technology. For more

information, visit www.qualishealth.org.

This material was prepared by Qualis Health as part of our work as the Washington & Idaho Regional Extension Center, under grant #90RC0033/01 from the Office of the national Coordinator for Health Information Technology, Department of Health and Human Services.


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